What further tests/screening might be helpful? Is referral to another healthcare provider indicated? Discussion One yellow flag is the client’s high level of constant pain and the description of her end-of-day pain as excruciating. Other yellow flags are not finding any position that relieves her pain, avoiding activity by going to bed, and hypervigilance about her pain. An orange flag is the diagnosis of depression. Referral to a mental health provider to address both depression and stress management may be appropriate. The client’s pain response to all movements and touch is a sign of central sensitization, which should be included in the diagnosis. One additional screening tool that may be helpful with this client is the Central Sensitization Inventory. Although a definite diagnosis is difficult to arrive at due to the client’s exaggerated pain response, a diagnosis of mechanical neck pain with central sensitization seems to fit. A plan of care that follows this diagnosis might logically include pain neuroscience education as well as stretching exercises and posture education. Case Study: Laura Long (Implicit Bias) Ms. Long was referred to home care physical therapy after cervical spine decompression and fusion related to a diagnosis of cervical myelopathy. The client’s home is in a trailer park and is in disarray, much of it related to her difficulty with managing her home due to her neck condition. The assessing physical therapist is uncomfortable in the client’s home. After assessing the client, the therapist decides the client would only need a minimal number of visits. How is this a case of implicit bias? In this case, the number of visits planned for this client was influenced by the client’s socioeconomic status (trailer park), not by her physical needs.
Case Study: Mandy Mason Ms. Mason is a 49-year-old female who presents to physical therapy via direct access with complaints of bilateral neck, shoulder, and upper back pain. She does not recall any specific cause of these symptoms but rather states that this is a chronic problem that comes and goes every few years. In the past she has tried physical therapy but states it only helped for an hour or two after each visit. The client’s medical history is significant for hypothyroidism, asthma, depression, and bipolar disorder. She describes her current pain as constant at 7/10 and says that it gets worse at the end of her workday so that it is “excruciating” by the time she leaves work. When she leaves her job as a social worker, she goes home and immediately goes to bed. She describes her job as stressful and overwhelming. She is not able to name any position, besides lying down, that alleviates her pain. Examination revealed full bilateral active upper extremity range of motion, although the client states that all the movements increased the pain in her upper back and neck. Upper extremity strength testing was confounded by the elicitation of pain. Cervical side bend and rotation were moderately limited in both directions and painful. She demonstrated a slouched posture but was able to correct it with cuing, stating that “my other physical therapist taught me good posture” then adding “but it hurts to sit up straight.” Assessment of facet joint mobility revealed mildly decreased upper cervical facet joint mobility and moderately limited upper thoracic joint motion with pain at all cervical and upper thoracic levels. Acute muscle tenderness and mild to moderate tightness was noted in the bilateral upper trapezius, levator scapula, scalene, and sternocleidomastoid muscles. Questions What yellow (orange) flags are present? Given the findings listed above, what diagnosis would you assign this patient? Conclusion Differential diagnosis is a critical part of the initial assessment of physical therapy clients. With direct access to physical therapy services, clinicians must be aware of potential systemic and viscerogenic conditions that might explain the client’s symptoms. Although infrequent, these situations can be serious and may necessitate referral to another healthcare provider. Once systemic and viscerogenic origins of cervical pain are eliminated, the assessing clinician can confidentially proceed with assignation of the appropriate diagnosis. This, in turn, helps determine the most effective plan of care so that the physical therapist can effectively treat the client’s presenting symptoms.
WORKS CITED https://qr2.mobi/headaches-spine
DIFFERENTIAL DIAGNOSIS FOR HEADACHES AND CERVICAL SPINE PAIN Self-Assessment Answers and Rationales
2. The correct answer is D. Rationale: Many patients with musculoskeletal injuries present with maladaptive pain coping strategies. It is not uncommon for clients to believe that their pain is a direct consequence of proportional tissue damage and to not understand the influence of maladaptive strategies such as catastrophizing. It is within the realm of physical therapy practice to recognize these maladaptive strategies and to provide pain neuroscience education to help the client understan d how these strategies are contributing to their pain experience.
1. The correct answer is A. Rationale: Only 1% of physical therapy cases are estimated to present as musculoskeletal injuries even though they originate from systemic or viscerogenic issues. Although this is a small percentage, differential diagnosis to identify viscerogenic and systemic issues is critical to effectively evaluating physical therapy clients.
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